This paper analyzes the policy model of the Brazilian Ministry of Health from 1990 to 2002. The methodology included interviews with key actors in the national health policy, document review, and analysis of the Federal budget and official databases. The Brazilian Ministry of Health underwent major changes under the influence of the health reform agenda and the liberal State reform agenda prevailing in the 1990s, shaped by two movements: institutional unification of national policy control and political/administrative decentralization. The Federal role was diminished in terms of direct services provision, and there were changes in financing and regulation. The model in the late 1990s featured strong Federal induction of States and municipalities and the adoption of market regulation strategies. There is no record of a long-term planning effort, which favors distortions in the Federal intervention model and hinders solutions to structural problems in the Brazilian health system.
This thesis examines the Brazilian municipalism after the Constitution of 1988. It verifies the municipalities performance in the provision of local health services vis--vis the decentralization of this policy due to the creation of the SUS (Unified Health System). It argues that the process of health services decentralization developed during the 90's presented two different steps: the step of autonomist decentralization, between 1990 and 1998, when the municipalities were totally free to choose their own local health policies; and the step of the driven decentralization, after the creation of the Basic Assistance Floor -PAB, when the municipalities started receiving targeted incomes, which could be used exclusively for specific health programs, determined by the Health Department. However, as we demonstrate, the both steps were incapable to decrease the extant regional inequalities in what regards the supply, the access and the financing of municipal health services. To summarize, we demonstrate that the inequalities in health produced by our federalism were not balanced through the outline of policies that municipalized the health services.
Christine Lao Peña, Ariadna García‐Prado, Olympia Icochea
In recent years, Central American countries have been implementing strategies to expand basic health services to remote and poor rural areas. In most cases, health extension services have been carried out by contracting with nongovernmental organizations (NGOs) and other nonpublic entities to manage or deliver health services. However, contracting with non-state providers has not been easily accepted in these countries as it is often seen as arising out of an ideological desire to privatize publicly financed health services or ultimately to limit or end government involvement in health care. This is what is happening in Honduras, where the Ministry of Health is promoting the extension of services with a community based approach within a decentralization strategy framework. The new health services extension models in Honduras rely on organizational and management arrangements that differ from the traditional Ministry of Health (MOH) health facility model. In particular, the facilities are managed by their communities under different legal and institutional arrangements, depending upon their organizational structures. Their staff are not civil servants, and, as a result, their management has considerably more flexibility in hiring and firing workers. In addition, they have multiple sources of financing. Patients contribute to the financing of these arrangements either with co-payments or pre-payments according to level of income (the sliding scale is determined by the community). The purpose of this study is to identify and compare the costs, efficiency, quality and coverage, as well as the institutional arrangements and organizational structure of the alternative models with one another, and with the traditional services delivery approach of the MOH to determine the feasibility of scaling-up these innovative models of extension of health services. To this purpose, we conducted a health facility survey to collect information on (i) Perceived quality, (ii) Technical quality, (iii) Accessibility (with regards to providers), (iv) Accessibility to communities, and (v) Price/out of pocket payments from users. In addition, the cost of providing key elements of the service package is estimated, including: (i) coverage for vaccination, well-baby care, prenatal care and curative consultations for acute respiratory infection and diarrheic disease, (ii) use of iron supplementation among pregnant women, (iii) knowledge and use of oral re-hydration among women, and (iv) use of vaccination cards for infants. Information on outputs produced have been collected based on these components, as well as their inputs over the last 3 months at each of the facilities. The cost of providing selected components of the basic package of health services in each type of facility was calculated. Results from our analysis show that even though the overall cost of service delivery in the new community models is higher, access to basic health services and quality of care, both technical and perceived, are generally better than in the traditional public health care facilities. Findings also indicate that the new models are more cost efficient than the traditional MOH health care centers suggesting the feasibility of either scaling up these new models and/or alternatively reforming certain aspects of the traditional health care facilities.
Bangladesh has made significant progress in health indicators in recent years in spite of her low level of income. This is mainly due to the commitment of the state supported by donors in providing preventive care with respect to child health and family planning. However, there are serious problems related to both access and quality of curative care that hurt the poor most. Infrastructures for service delivery exist at local level in rural areas but they function inefficiently. This paper deals with the systemic weaknesses of decentralized service provision of primary healthcare in Bangladesh and focuses on accountability links between different actors and functions of delegation, finance, performance, information and enforcement. The study is based on facility- and household-based data collected during 2005 in Khulna Division. The main findings of the study are: the health system in rural areas represents deconcentration rather than decentralization of central government functions where inter-sectoral discipline works poorly; local health providers are not accountable to local government, and poor citizens/clients are neither aware of their rights nor are capable of expressing their needs as effective channels do not exist.
<abstract language="eng">The constitution of Brazil directs that the country’s health system, the Unified Health System (Sistema Único de Saúde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil’s federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil’s health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
The constitution of Brazil directs that the country's health system, the Unified Health System (Sistema Unico de Saúde), be politically and administratively decentralized. Nevertheless, handing over competencies, responsibilities, and resources to subnational levels, especially to municipal governments, has been a slow process, lasting almost two decades. Advances have been brought about by the Unified Health System, which, from a analytical perspective, is a public and universal system. Despite that, the decentralization process needs to overcome norms that keep all levels of management dependent on Brazil's federal Government. The subnational levels have consistently faced difficulties in performing their macromanagement functions with autonomy, especially when it comes to financing and to the establishment or organization of health care networks. Boldness and responsibility will be needed to prevent Brazil's health decentralization process from leading to fragmentation. New political agreements between different levels of government, with a reassignment of responsibilities and the enhancement of a culture of technical cooperation, are fundamental requisites to making the Unified Health System have a health policy that is truly public and universal.
Contracting is one of the tools increasingly being used to enhance the performance of health systems in both developed and developing countries; it takes different forms and cannot be limited to the mere purchase of services. Actors adopt contracting to formalize all kinds of relations established between them. A typology for this approach will demonstrate its diversity and provide a better understanding of the various issues raised by contracting. In recent years the way health systems are organized has changed significantly. To remedy the under-performance of their health systems, most countries have undertaken reforms that have resulted in major institutional overhaul, including decentralization of health and administrative services, autonomy for public service providers, separation of funding bodies and service providers, expansion of health financing options and the development of the profit or nonprofit private sector. These institutional reshuffles lead not only to multiplication and diversification of the actors involved, but also to greater separation of the service provision and administrative functions. Health systems are becoming more complex and can no longer operate in isolation. Actors are gradually realizing that they need to forge relations. The simplest way to do that is through dialogue, although some prefer a more formal commitment. Interaction between actors may take various forms and be on different scales. There are several types of contractual relations: some are based on the nature of the contract (public or private), others on the parties involved and yet others on the scope of the contract. Here they are classified into three categories according to the object of the contract: delegation of responsibility, act of purchase of services, or cooperation.
China's transition into a market economy has exerted some influence on the health sector in terms of a significant growth of facilities, but it has also produced a range of destabilizing social costs. \n \n \n \nThis thesis analyzes the relations between healthcare pricing and payment reforms and the different delivery aspects such as the exemption program for the poor, public health programs for tuberculosis control and the provision of hospital services. A health economics and systems conceptual framework is used for analyzing aspects of the health systems in terms of market failures and the institutional response from governments and regulators. \n \n \n \nIn study I, the exemption programs for hospitals where the poor are relieved of paying the price or user charges are analyzed. The study is a case study where patient records from nine hospitals were reviewed, together with interviews with key informants and community representatives. The study showed that the discount offered was limited, where only a minority of indigents received discounts and the hospitals lacked incentives for efficiently carrying out the programs. \n \n \n \nStudy II investigates the effect of the new urban health insurance system on hospital charges. The study uses two tracers, acute appendicitis and normal childbirth, at six hospitals from two cities with different insurance systems. The result showed a lower rate of increase in hospitals charges in the city implementing the urban health insurance reform. Regression analysis showed contracting mechanisms and length of stay to be the main determinants for hospital charges. \n \n \n \nStudy III analyzes the operation of TB control programs in a decentralized financial system. A case study was conducted in four counties with different economic developments in the Shandong province. Data was collected from a review of documents and interviews with patients and key informants. The study showed weak government support to the TB control program and less developed DOT (directly observed therapy) programs in the poorer counties. TB patients suffered heavy financial burdens. The decentralized financing system had negatively affected the provision of public health programs such as TB control programs. \n \n \n \nIn study IV, the impact of retail price control of drugs on hospital drug expenditures was examined. The study is a case study at two hospitals. Total drug expenditures were analyzed based on financial records and a tracer, cerebral infarction, was used for an in-depth examination of prices, volume, expenditures and rationality of drug use. Findings showed that after the implementation of the drug pricing policy, total drug expenditures increased as rapidly as before. Drug expenditure per patient for cerebral infarction showed indistinct results, indicating that the regulation was not effective. Utilization rather than price was more determinative for drug expenditures. \n \n \n \nStudy V investigates the development of revenues, costs and performance in the hospital sector. In a sample of 41 hospitals in two cities, the use of inputs, investments and productivity was estimated. The findings showed that hospitals had expanded their staff and invested in new medical equipment. The corresponding change of outputs in terms of outpatient and inpatient performance showed a slower increasing rate, resulting in a diminishing productivity rate over time. \n \n \n \nThe market-oriented health care system in China is faced with different 'market failures' problems such as limited access to health services for the poor and the inaccuracy in relying on market mechanisms for services characterized by positive externalities, such as the public health programs. Financial autonomy has given health providers the incentives to maximize revenues. Government interventions to contain costs and improve efficiency show that a sole reliance on the price mechanism is insufficient and must be combined with other tools set by regulators and insurers.
OBJECTIVE: To identify the effects of decentralization on health financing and governance policies in Mexico from the perspective of users and providers. METHODS: A cross-sectional study was carried out in four states that were selected according to geopolitical and administrative criteria. Four indicators were assessed: changes and effects on governance, financing sources and funds, the final destination of resources, and fund allocation mechanisms. Data collection was performed using in-depth interviews with health system key personnel and community leaders, consensus techniques and document analyses. The interviews were transcribed and analyzed by thematic segmentation. RESULTS: The results show different effectiveness levels for the four states regarding changes in financing policies and community participation. Effects on health financing after decentralization were identified in each state, including: greater participation of municipal and state governments in health expenditure, increased financial participation of households, greater community participation in low-income states, duality and confusion in the new mechanisms for coordination among the three government levels, absence of an accountability system, lack of human resources and technical skills to implement, monitor and evaluate changes in financing. CONCLUSIONS: In general, positive and negative effects of decentralization on health financing and governance were identified. The effects mentioned by health service providers and users were related to a diversification of financing sources, a greater margin for decisions around the use and final destination of financial resources and normative development for the use of resources. At the community level, direct financial contributions were mentioned, as well as in-kind contributions, particularly in the form of community work.
Decentralization of health services in Uganda, driven by the structural adjustment programme of the World Bank, was embraced by government as a means to change the health institutional structure and process delivery of health services in the country.Arising from the decentralization process, the transfer of power concerning functions from the top administrative hierarchy in health service provision to lower levels constitutes a major shift in management, philosophy, infrastructure development, communication as well as other functional roles by actors at various levels of health care.This study focused its investigation on ways and levels to which the process of decentralization of health service delivery has attained efficient and effective provision of health services.The study also examined the extent to which the shift of health service provision has influenced the role of local jurisdictions and communities.Challenges faced by local government leaders in planning and raising funds in response to decentralized health service delivery were examined.The study used a descriptive survey research design employing qualitative techniques, namely questionnaires, structured interviews, observation, and document analysis to establish the extent to which the decentralized approach to health service delivery has impacted on local governments and the vulnerable target groups such as the rural and urban poor, children, mothers, HIV/AIDS victims, orphans and refugees.Key respondents were government officials in health related management in the country at various levels.Health workers and beneficiaries of health services were interviewed to share their views and experiences of decentralized health care service provision.iii Using a conceptual framework of "Community as Client", the findings illustrate that while some local governments in the country have extended health units closer to some communities, the pursuit of a decentralized health service delivery system in Uganda over-assumed the benefits of decentralizing health care.The observations indicated that health care is not better organized; neither has decentralization provided greater involvement of local communities in mobilization and capacity building of community-based health workers.The acclaimed cost containment and reduction through duplication of services, reduction of inequities, integration of activities of different agencies and organizations involved in health care have not been achieved in concert with original expectations and assumptions of decentralization.These include: strengthened health policy and planning functions of the ministry of health, improved implementation of health programmes, greater community control and financing (ownership) and improved inter-sectoral coordination.From the findings, it would appear that the motivation for decentralizing health care was not intrinsically guided by how the decentralized health system can better serve the poor majorities in the country.The study concludes that the decentralization of health services in Uganda was not matched with commitment for provision of necessary health supplies, and delivery of health care services through a centrally coordinated national network of health facilities.The Ugandan Government in particular Ministry of Health and the government needs to evaluate the achievements and challenges faced by the health care system under decentralization within the broader perspective of health for all, as a means to establish appropriate refocusing of health care delivery for optimal benefit of the client communities.
India has set out ambitious goals for itself in the health sector in its Tenth Five Year Plan (2002-07). It is also a signatory to the United Nations Millennium Development Goals. Attainment of these goals which are time-bound will require a massive scaling up of investment in health, especially in public primary health care. We argue for a ‘Health for All’ initiative on the part of the government akin to the ‘Education for All’ scheme which was launched nation-wide in 2001. The large amount of resources required for scaling up public investment in primary health need not be the constraint it is purported to be. We discuss several options that are available to the government for generating the necessary funds. Among the options that can generate resources domestically are reform of the government’s subsidies regime including implementing life-line tariffs, ear-marking taxes and disinvestment of loss-making public sector units. Health for All can also be financed by raising more resources via external assistance. Official development assistance to India at present is rather low given India’s per capita income and the scale of its needs in human development terms. The scale of official development aid to India should increase several folds and committed use of funds should be made by the government in health and other priority sectors. With the 73rd and 74th amendments to the Indian Constitution which created a third tier of government comprising of elected local bodies at the village and town ward levels, a decentralized system of service delivery will eventually become a reality in India and needs to be a part of any debate on the means and modes of improving human development outcomes in India. The current system of planning and allocation of funds at the sub-national level however needs to be over-hauled if fiscal decentralization is also to become a reality.
OBJECTIVE: To assess the equity and fairness of the Mexican health system reform that occurred in the late 1990's. MATERIAL AND METHODS: The Mexican reform process was evaluated using the benchmark-system designed by Daniels et al. This benchmark system was adapted to the Mexican setting by adding specific indicators. A documentary review of the Mexican reform process was conducted to score its performance for each benchmark. RESULTS: Except for housing and nutrition components, the reform included few actions related to health determinants. For health care, the main reform initiatives were those related to extending the coverage of essential health services and decentralizing health care provision to the states. Reform initiatives included few activities related to fair financing, tiering, emphasis on second and third level care, accountability, and transparency. CONCLUSIONS: The late nineties reform of the Mexican health system had some positive effect on access of the poor to health care and administrative efficiency, but little impact on fair financing, quality of care, and democratic governance. The English version of this paper is available at: http://www.insp.mx/salud/index.html.
This paper examines the concept and practice of community participation in World Bank-supported health sector reforms in Asia, and how far such participation has strengthened accountability with regard to provision of sexual and reproductive health (SRH) services. It argues that the envisaged scope of community participation within a majority of reforms in Asia has been limited to programme management and service delivery, and it is occurring within the boundaries of priorities that are defined through non-participatory processes. Setting up of community health structures, decentralization and community financing are three important strategies used for promoting participation and accountability within reforms. The scant evidence on the impact of these strategies suggests that marginalized groups and sexual and reproductive rights based groups are poorly represented in the forums for participation, and that hierarchies of power between and amongst health personnel and the public play out in these forums. Community financing has not lead to enhanced service accountability. As a result of the above limitations, community participation in health sector reforms has rarely strengthened accountability with respect to provision of comprehensive SRH services. In this context, rights (including sexual and reproductive) based groups and researchers need to engage with design, monitoring and evaluation of health sector reforms, both from inside as participants and outside as pressure groups. Participation contracts enhancing powers of civil society representatives, quotas for participation (for women, other marginalized groups and rights-based organizations), and investment in capacity building of these stakeholders on leadership and sexual reproductive rights and health are pre-requisites if participation is to lead to health and SRH service accountability. Community participation and service accountability hence requires more and not less investment of resources by the state.
The severe acute respiratory syndrome (SARS) crisis in China revealed not only the failures of the Chinese health-care system but also some fundamental structural deficiencies. A decentralized and fragmented health system, such as the one found in China, is not well-suited to making a rapid and coordinated response to public health emergencies. The commercial orientation of the health sector on the supply-side and lack of health insurance coverage on the demand-side further exacerbate the problems of the under-provision of public services, such as health surveillance and preventive care. For the past 25 years, the Chinese Government has kept economic development at the top of the policy agenda at the expense of public health, especially in terms of access to health care for the 800 million people living in rural areas. A significant increase in government investment in the public health infrastructure, though long overdue, is not sufficient to solve the problems of the health-care system. China needs to reorganize its public health system by strengthening both the vertical and horizontal connections between its various public health organizations. China's recent policy of establishing a matching-fund financed rural health insurance system presents an exciting opportunity to improve people's access to health care.
Decentralization policies are an integrated component of health sector reform in an increasing number of countries. The ability of such policies to improve the health system's quality and efficiency is backed up by limited scientific evidence. This study intends to evaluate the impact of decentralization on a specialized field of disease control (leprosy control) in Colombia and Brazil. It analyses the respective juridical base, epidemiological indicators and local publications. Furthermore, 39 semi-structured interviews with key informants were conducted. In both countries, the devolution of technical responsibility and financial resources to the municipalities was the implemented form of decentralization. Access to preventive and curative health care and the community participation in decision-making improved clearly only in Brazil. The decentralization to private providers in Colombia had dubious effects on service quality in general and still more on public health. The flow of finances (including finance collection through state-owned taxes instead of insurance companies) seemed to be better controlled in Brazil. Leprosy control in Brazil took advantage of the decentralization process; in Colombia, it came close to a collapse.
Latin American social medicine (LASM) emerged as a movement in the 1970s and played an important role in the Brazilian health care reform of the 1980s, both of which focused on decentralization and on health care as a social right. The dominant health care reform model in Latin America has included a market-driven, private subsystem for the insured and a public subsystem for the uninsured and the poor. In contrast, the Mexico City government has launched a comprehensive policy based on social rights and redistribution of resources. A universal pension for senior citizens and free medical services are financed by grants, eliminating routine government corruption and waste. The Mexico City policy reflects the influence of Latin American social medicine. In this article, I outline the basic traits of LASM and those of the prevailing health care reform model in Latin America and describe the Mexico City social and health policy, emphasizing the influence of LASM in values, principles, and concrete programs.
Nazmul Chaudhury, Jeffrey S. Hammer, Edmundo Murrugarra
This study examines the impact of a fee-waiver program for basic medical services on health care utilization in Armenia. Due to the reduction in public financing of health services and decentralization and increased privatization of health care provision, private out-of-pocket contributions are increasingly becoming a significant component of health costs in Armenia. To help poor families cope with this constraint, the Government of Armenia provided a free-of-charge basic package service to eligible individuals in vulnerable groups, such as the disabled and children from single parent households. Drawing upon the 1996 and 1998/99 Armenia Integrated Survey of Living Standards (AISLS), which allows the identification of eligible individuals under this program, we estimate the impact of the fee-waiver program on utilization of health services, particularly among the poor. Across the two survey rounds utilization rates have indeed declined despite comparable levels of income, and this decline has occurred among both the poor and the rich, with average utilization falling by 12 percent between the two surveys. However, families with four or more children, the largest beneficiary group under the &quot;Vulnerable Population&quot; program, have decreased their usage of health care services in a disproportionate manner -- 21 percent reduction in usage between the two survey rounds. This precipitous drop in health care usage by this vulnerable group despite being eligible for free medical services, suggests that the program just by itself was inadequate in stemming the decline in the usage of health services. We furthermore present evidence to suggest that the free-of-charge eligibility program is acting more like an income transfer mechanism, particularly to disabled individuals. Contents...
The current need and enthusiasm for health reforms open an important arena for deeper analysis of the policy process with a view to understanding the political determinants of reforms and strengthening implementation. The studies described in this thesis analyse positions of different actors in the reform process, their actions in support or opposition of the process, and their impact on the health sector reform process. Globally and especially in developing countries health sector reforms have been implemented over long periods. Although there have been improvements in health, the remaining burden of disease in many countries is still very high. Reasons for the high burden of disease have been classified into lack of resources and poor organizational and managerial capacity. Good stewardship was needed to facilitate improvement in the performance of health systems. Stakeholders’ alignment and support was one of the most important components of good stewardship. However, stakeholder analysis had not been a common undertaking in developing countries despite the reforms that were being implemented in most of them. It was the aim of this study to answer the question: What has been the role and importance of stakeholders in supporting or opposing the health sector reform process? The study was conducted in Tanzania as one of the poorest countries in Africa, using the decentralization of the Expanded Programme on Immunization (EPI) as a case reference. The study units were the Ministry of Health Headquarters, Medical Stores Department, Expanded Programme on Immunization, national archives, regions and districts. At district level the study units were District Council, Council Health Management Team, EPI managers at regional and district levels, ward and village authorities, health facility, facility providers and households. Qualitative and quantitative methods were used to collect data from January 2000 to June 2002. Relevant data collection instruments were prepared and pre-tested. The qualitative data collection methods included document review, \nin-depth interviews, key informants interviews and observations. Quantitative \nmethods involved retrieval of secondary data, health facility survey and \nhousehold surveys. Regular discussions with key informants and data \ncollectors were held to verify the findings. Qualitative data was analysed \nmanually. Quantitative data was captured and analysed using Epi Info version \n6.1 and STATA version 6.0. The study involved answering five main questions. The first question was: Do \nreforms learn from history? Analysis of the waves of health reforms prior to \nthe current reforms from 1926 was done to answer the question. The main \nstakeholders in the reforms were the political party in power, the government \nand donors who supported the reforms each time. Each wave of health sector \nreforms provided information on health provision, financing and resource \ngeneration. Due to the political contexts, information on failures of health \nfinancing did not provide lessons for succeeding reforms of the health sector. \nStakeholders’ political interests opposed lessons that did not match the \npolitical ideology at the time i.e. free public services versus privatization and \npaying for social services. Lessons from previous health reforms were \nselective, and did not consider health-financing needs among others. The \nongoing health reforms needed to use information from all functional aspects \nof the health system to provide lessons for improving the health system. The second question was: Who were the stakeholders in the current health \nreforms and what were their interests and reactions? The main stakeholders \nwere donors, and the government. The two had a very high support for the \nreforms evidenced by their participation in problem identification, justification, \nreform design, planning and implementation. The health sector reforms thus \nhad high political support at central level. In the implementation process, \nissues that triggered stakeholders’ reaction included sectoral versus local \ngovernment decentralization. Another issue was the donor modality in \nfinancing the health sector and need for adopting new financial management \nsystems. Among the donors there was hesitancy to join the common financing \nmodalities that included a Sector Wide Approach (SWAp) and Basket \n Funding. As a result, there was delay in the process in order to reach better \nconsensus. \nThe third question was: What was the impact of stakeholders in the process of \nreforming a vertical programme like EPI? Health Sector Reforms in EPI \nincluded integration of generic functions, for example, vaccine procurement to \nmedical stores department. Qualitative and quantitative data was collected \nand analysed from the Ministry of Health, EPI management unit. This again \nrevealed that EPI reforms were well supported by the government and donors \ncentrally. EPI managers at both district and regional levels opposed some of \nthe EPI reforms. They argued that coverage was falling due to the reforms. \nHowever, there was no concrete evidence relating reforms in the EPI \nprogramme and falling coverage. The primary aim of certain actors was to \nmake sure that they continued receiving extra income from EPI functions. One \nof the effects of stakeholders’ reaction was reversal of reforms (recentralization) \nand return to the status quo. The fourth question was: What was the immediate reaction of stakeholders to \ndecentralization at district level and how might it have affected performance of \nEPI functions and the challenges? The immediate reaction of stakeholders \nwas reduced cooperation between the Council Health Management Team \n(CHMT) and the District Council who were politically supreme in the district. \nWithin the Council Health Management Team there was inadequate \ncommunication, which led to poor teamwork. The result of this was reduced \nsupervisory visits to peripheral health facilities. The EPI coverage in the study \ndistrict was 52.8 per cent, which was well below the previous national average \n(80 per cent). A logistic regression model for EPI service quality variables on \nchildren between 12 months and 23 months who had completed vaccination \nwas applied. Certain EPI quality of service variables predicted significant \nchanges in the odds ratio for completing vaccination. It was then suggested \nthat strategies were needed to improve management skills among the CHMT \nand District Council members. Also there was a need of hastening the \nprocess of increasing remuneration and motivation of peripheral health \nworkers. The fifth and final question was: What was the interest of the stakeholders \nand prospects of increasing EPI coverage at district level? Decentralization \nand integration of EPI functions were among the reforms at district level. The \nanalysis revealed that active stakeholders at district level were the Ministry of \nHealth, CHMT, EPI managers at district and regional levels and facility \nproviders. The Ministry of Health opposed integration of EPI at district level by \nissuing the directive that DCCOs and MCHCOs (EPI manager at district level) \nshould resume their tasks. However, the CHMT had no option but to comply. \nThis action reversed some of the health reforms at district level. Analysis of \nthe importance the community attached to EPI, using willingness to pay for \nEPI cold chain kerosene, was done. The support was low (48.7 per cent). EPI \nservice quality variables were significantly negatively associated with odds \nratio for willingness to pay for EPI input. Simulation with Policy Maker \ncomputer software predicted that an increased number of stakeholders \nthrough community participation would significantly improve the current low \nlevel of EPI coverage. It was then proposed to do a similar analysis in other \nvertical programmes and implement on a trial basis the results of the \nsimulation. \nIn conclusion, stakeholders were found to be active and influential in the \nhealth sectors of developing countries like Tanzania but poorly considered in \nimplementation of reforms. Stakeholders are important since some strongly \nsupport while others oppose the reforms. The reaction of stakeholders is \nevident through deployment or non-deployment of information depending on \ninterest and context. This would result in poor management leading to \ninefficiency in resource use, which would then be followed by poor quality of \nservices, poor support by communities and consequently poor utilization of \nhealth services. It is suggested that stakeholder analysis be conducted in \nother vertical programmes in the process of integration. Promotion of \nstakeholder analysis and also Policy Maker as a tool to manage stakeholders \nwill facilitate the management of reforms in the health sector.
The introduction of user-payment for health services is frequently followed by concern about the impact on equity of access for poor people. Decentralizing governments often try to remedy the created inequities by putting in place safety nets in the form of exemptions and waivers in the user-fee systems. However, where user payments merely operate as local government strategies for health financing, without national policy they are likely to be self-defeating, as local governments are frequently more interested in raising revenue to meet recurrent costs of devolved services than in promoting equity. Thus guidelines put in place by the central government to operationalize safety nets are seen by local governments as being contradictory to this goal, and are thus ignored or altered to suit the district revenue aims. This study was carried out to investigate the context and the constraints in implementing exemption schemes. Data were collected in two selected administrative districts of Uganda (Mbarara and Mukono). Qualitative approaches to data collection were adopted, namely focus group discussions and key informant interviews with policy-makers, health administrators, service providers and community members. These methods were combined with document review. We found little evidence of safety-net guidelines initiated by decentralized/local governments, since district local governments had little motivation to extend exemptions, waivers or credits. The conclusion is that safety nets such as waivers and exemptions will only be effective if they are backed by a national health financing policy, they reconcile the often competing demands of local government revenue needs, and are strictly enforced and supervised by both the local and central governments. The implications of the findings for remedying the tension between the needs for cost recovery and for attainment of equity goals through exemption policies for the poor and indigent are discussed.
Decentralization is commonly championed as a means for achieving equity. To date, however, there has been little discussion of the mechanisms underlying this relationship, and several of the few empirical investigations that have addressed the topic have found the converse; that decentralization has exacerbated inequalities. This article examines the performance and equity in financing of the Honduras Ministry of Health's (MOH) decentralized user fee system. The MOH of Honduras established a national user fee policy in 1989. It provided a framework of rules and regulations and decentralized administration of the system to the regional offices. A survey conducted under the auspices of this study provided detailed information about the structures and operations of MOH user fee systems. The survey revealed that the systems vary markedly by region, creating horizontal inequities, and that they have numerous other shortcomings. The average price of a consultation is low, US dollars 0.16, and revenues have consistently equalled just 2% of MOH expenditures. The systems' administrative costs are equal to 67% of their revenues. Eliminating the user fee systems in all but the national and regional hospitals would actually save money and/or enable the MOH to provide more care. Average consultation prices are highest in health posts, intermediate in centres and lowest in the national hospitals, thereby encouraging the inappropriate use of the MOH's pyramidal referral system and fostering MOH inefficiency. Fee levels and exemption practices are horizontally and vertically inequitable. The likelihood of paying for an ambulatory visit is highest at a health post, 89%, and lowest at a hospital, 49%. Individuals from the poorest one-fifth of households are the most likely to have to pay for care. Honduras' experience demonstrates that a decentralized user fee system is not necessarily equitable, and that, more generally, the gains that can be realized from decentralizing user fee systems are not automatic. They must be anticipated, planned for and cultivated by a well-designed and well-implemented initiative that is not a single, one-time event, but rather a dynamic, on-going enterprise.
OBJECTIVE: The results of an evaluative longitudinal study, which identified the effects of health care decentralization on health financing in Mexico, Nicaragua and Peru are presented in this article. METHODS: The methodology had two main phases. In the first, secondary sources of data and documents were analyzed with the following variables: type of decentralization implemented, source of financing, funds for financing, providers, final use of resources, mechanisms for resource allocation. In the second phase, primary data were collected by a survey of key personnel in the health sector. RESULTS: Results of the comparative analysis are presented, showing the changes implemented in the three countries, as well as the strengths and weaknesses of each country in matters of financing and decentralization. CONCLUSIONS: The main financing changes implemented and quantitative trends with respect to the five financing indicators are presented as a methodological tool to implement corrections and adjustments in health financing.
The paper reviews the theoretical basis for the application of user fees in the public health sector in low-income countries with particular reference to the special characteristics of medical care as a commodity. The general equilibrium efficiency result of the market mechanism is shown to be the theoretical justification for the financing of health services via a system of user charges. If markets for all goods and services exist, and are perfect in a very strict sense, the welfare outcome of the price mechanism cannot be improved upon by any other resource allocation device. Furthermore, the decentralized and impersonal nature of this mechanism renders it more convenient to use in the allocation of commodities, health care included, than its alternatives such as a system of centrally administered prices or a system of administrative controls and directives. However, since many of the assumptions of the price system are rarely met in actual situations, especially in the health sector, it should be applied with caution. In particular, problems of information asymmetry and consumption externalities in health care markets necessitate a simultaneous use of fees with government interventions in order for fees to achieve their often intended aim of efficiency and equity improvement in health care provision. The most important intervention of the government here is the enactment and enforcement of institutions that reduce costs of transacting in health care markets and that in addition facilitate the emergence of new markets such as the markets for medical insurance. A striking finding of the paper is that health services in low-income countries are best financed primarily by revenue from general taxation, supplemented by a system of moderate user fees. Since medical insurance markets are generally non-existent in low-income areas, it is argued that financing health services primarily through user fees in such areas would be inefficient and inequitable. However, to mitigate the moral hazard problem as well as the problem of the commons, both of which characterize publicly financed health care, imposition of modest user fees is required. The importance of fees in this proposal increases with economic growth and with evolution of institutions that facilitate market transactions. Strategic interaction among economic agents is shown to affect the structure and implementation of user fees. A game-theoretic analysis of the general problem of health care financing shows that this problem is best tackled by harnessing the efforts of households, private health care providers, the government and civil society. These entities form what might be called a winning coalition in health care financing game of society. It is argued that the government is better placed to provide an institutional framework for coordinating the efforts of the various players to the desired end.
Brotowasisto, Oscar Gish, Ridwan Malik, Paramita Sudharto
This paper describes health care financing and expenditures in Indonesia, a developing country spending around $US 9.40 per capita annually for health care (2.6% of GOP). Per capita health care spending has held constant in real terms over the last five years. The public sector accounts for 36.8% of all health care expenditure, or 43.1% if health care spending by state enterprises is included. About 13% of the population, almost all of them government employees and their families, are covered by some form of health insurance. In 1984, 62% of the population was spending privately – at then current exchange rates – an average of $US 2.70 per capita annually for health care, another 30% averaged $US 8.35 each, and the upper 9% $US 31.90. The Government is reviewing various ‘social financing’ mechanisms with a view to expanding health insurance coverage both for those in formal wage employment and the bulk of the population which remains either on the land or is part of the ‘informal’ sector. Steps are also being taken to increase the efficient use of resources by, among other things, making greater use of evaluation techniques and economic methodologies. Such efforts are coupled with more decentralized authority being given to the provinces and districts. Particularly important to future health efforts is the further expansion of community-based activities, especially in the form of the Posyandu (integrated health post).
On behalf of the American Association of Neurological Surgeons/Congress of Neurological Surgeons Joint Section on Disorders of the Spine and Peripheral Nerves, it is my great privilege to introduce these Guidelines for the Management of Acute Cervical Spine and Spinal Cord Injuries. These guidelines represent the initial installment of a more comprehensive guidelines initiative from the Joint Section on behalf of all practicing neurosurgeons and their patients. The Section is grateful to the small working group who devoted considerable time and effort to the generation of this outstanding document. We would like to formally recognize the Joint Section on Trauma for their important collaboration on this project. The Section would also like to acknowledge and thank the parent organizations, the American Association of Neurological Surgeons and the Congress of Neurological Surgeons, for their guidance of and support for this project, most notably through the efforts of the American Association of Neurological Surgeons/ Congress of Neurological Surgeons Guidelines Committee. The Section is also deeply indebted to Michael Apuzzo and the staff of Neurosurgery for their advice and editorial assistance in preparing this document for publication. The application of Neurosurgery’ s rigorous peer-reviewed editorial process has clearly enhanced the quality, balance, and stature of this document. Perhaps most importantly, Neurosurgery has provided an extraordinary vehicle for the widespread dissemination and ultimate incorporation of these guidelines to improve the care and enhance the outcomes of patients with traumatic cervical spine and spinal cord injuries. One of the truly important functions of organized neurosurgery is the generation of evidenced-based clinical practice guidelines. Properly developed, such guidelines can answer important questions, resolve uncertainty, identify areas of deficient knowledge and opportunities for future scientific investigation, standardize treatment, and improve the quality of care and the outcomes for patients. The now widely disseminated head trauma guidelines, for example, have clearly made a difference in the outcomes of patients with severe head injury. Guidelines development is a highly structured process with rigorous methodological criteria and exacting standards. It is a time-, labor-, and resource-intensive process that has served as a significant obstacle to more widespread guidelines development throughout neurosurgery. In the past, clinical practice guidelines have been developed by publicly supported epidemiologists and methodologists who understood study design, data analysis, and the guidelines process, but not the disease. This absence of context and clinical perspective significantly limited the value and relevance of their results. Alternatively, clinician-generated guidelines often took the form of methodologically flawed consensus panels and expert opinion, also of limited value. The Joint Spine Section recognized the importance of evidence-based clinical practice guidelines and the challenges of their development. The appropriate clinical expertise, strict adherence to established methodological standards for guidelines development, and considerable resource investment for the development, dissemination, and maintenance of the guidelines documents were deemed crucial to our guidelines initiative. Cervical spine and spinal cord injury was chosen as the initial guidelines topic because of the personal, social, and economic devastation of these injuries, their complex nature, and the high level of uncertainty, as reflected in wide practice variations, as to the value and indications for many of the aspects of evaluation and treatment. The clinical practice guidelines contained in this supplement to Neurosurgery represent a remarkable effort. They address the key issues related to the evaluation and management of these complex conditions that are relevant to the treating physician. In every chapter, the pertinent issues are succinctly stated, the published data are comprehensively presented in the evidentiary tables, and the evidence is thoroughly discussed and critically evaluated throughout the text. The linkage between the quality of the evidence and the strength of the recommendations was not a “black box” process but an open, deliberative exercise by skilled experts guided by a rigorous set of standards. Despite the strength and potential value of this document, it is important to acknowledge the inherent limitations of clinical practice guidelines. This, or any other, evidence-based clinical practice guidelines document does not represent the definitive source of knowledge on the stated topic. Rather, it represents recommendations of varying strength and certainty based on an analysis of the best available published data. These data, however, are often conflicting, flawed, or incomplete, and there are unavoidable elements of potential bias from subjectivity, perspective, and experience of the individuals and group involved in the analysis and interpretation of these data. In essence, proof is a relative term based on the interpretation of evidence. Furthermore, it is subject to different standards. A relevant example comes from the field of jurisprudence, where the standard of proof (i.e., guilt) for criminal trials is “beyond a reasonable doubt,” whereas the standard for civil courts must simply reflect “a preponderance of evidence” or “more likely than not.” These different standards evolved because of the perceived different consequences of a wrongful verdict. Moreover, as Stephen Haines likes to note, the verdict “not guilty” does not mean innocent; it merely says not proved. Such are the vagaries associated with the interpretation of even scientific evidence. Principled people can look at the same evidence and come to different conclusions subject to their own personal perspective, experience, and stake in the result. Nevertheless, the Joint Section and Guidelines Development Group went to great lengths to identify and avoid—or at least minimize—these potential problems. The working group adopted the most widely recognized and rigorous standards for guidelines development. A diverse panel of experts with expertise in spine, trauma, and epidemiology brought relevant clinical, scientific, and methodological competence to enhance both the analytical and the deliberative aspects of this process. Periodic outside reviews were routinely obtained for topics or areas of contention or uncertainty to add additional perspective and balance. Above all, the process was accountable and transparent at every stage. Ultimately, we offer these guidelines as a living document to those professionals who treat patients with traumatic spinal injury. We hope each practitioner will critically evaluate these guidelines and come to his or her own conclusion on how, whether, and when to implement its recommendations. It may be used either as a reference or as a basis for standardized protocols of evaluation and management of the patients with traumatic spinal injury. For clinical and basic science researchers, we hope that it will identify and catalyze scientific investigation in areas of deficient knowledge. As a Section, we stand firmly behind this important document and will continuously update the recommendations as new knowledge and understanding is developed. We sincerely believe that these guidelines can improve the care and enhance the outcomes of patients with traumatic injuries to the cervical spine and spinal cord.